A nurse is providing teaching for a client who has an ileal conduit following bladder cancer. Which of the following statements by the client indicates a need for the nurse to provide additional teaching?
I need to catheterize the stoma several times a day.
I will need to measure my stoma each week.
I will always have to wear a pouch.
I need to cleanse around the stoma with soap and water.
The Correct Answer is A
Choice A reason: This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.
Choice B reason: This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.
Choice C reason: This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.
Choice D reason: This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. Muscle weakness.
Choice A: Hypertension
Reason: Hypertension, or high blood pressure, is not a typical manifestation of hypokalemia. Hypokalemia primarily affects muscle function and the nervous system. While potassium imbalances can influence blood pressure, hypertension is more commonly associated with hyperkalemia (high potassium levels) rather than hypokalemia.
Choice B: Cerebral Edema
Reason: Cerebral edema, which is swelling of the brain, is not a known manifestation of hypokalemia. Hypokalemia affects muscle and nerve function, but it does not directly cause cerebral edema. This condition is more related to severe head injuries, infections, or other medical conditions.
Choice C: Muscle Weakness
Reason: Muscle weakness is a common and significant manifestation of hypokalemia. Potassium is crucial for muscle function, and low levels can lead to muscle weakness, cramps, and even paralysis in severe cases. This is because potassium helps in the transmission of nerve signals to muscles, and a deficiency disrupts this process.
Choice D: Hyperactive Bowel Sounds
Reason: Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, hypokalemia can lead to decreased bowel motility, resulting in symptoms like constipation or ileus (a condition where the intestines do not move properly). This is due to the role of potassium in muscle contractions, including those in the digestive tract.
Correct Answer is A
Explanation
Choice A reason: This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.
Choice B reason: This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.
Choice C reason: This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.
Choice D reason: This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
